Laparoscopically assisted total gastrectomy with jejunal pouch interposition

Background Jejunal pouch interposition (JPI) is known as a useful gastric replacement procedure after total gastrectomy. The JPI procedure, however, has not been applicable to laparoscopically assisted total gastrectomy (LATG) because of its technical complexity and difficulty. This study aimed to describe our modified LATG/JPI technique, and to evaluate its feasibility, safety, and early postoperative functional outcome. Methods Between September 2002 and August 2003, LATG/JPI was attempted for five patients (3 men and 2 women) with early gastric cancers in the upper portion of the stomach. The mean age of the patients was 57 years, and their BMI was 21 kg/m². Using a 5-port technique, the gastric arteries were laparoscopically clipped and divided with adequate lymphatic dissection. After completion of gastric resection, the anvil of a circular stapling device was placed in the esophageal stump. An 8-cm minilaparotomy then was performed, and the 12-cm pouch was created extracorporeally in the “reverse U” fashion. The stapled pouch-esophagostomy was performed under laparoscopic monitoring. The remainder of the procedure was accomplished under direct vision. Results All cases were managed laparoscopically without any complications. The mean operating time was 407 min, and the blood loss was 279 ml. All the patients showed rapid and uneventful recovery. Postoperative studies, including dual scintigraphy, showed that all jejunal pouches were satisfactorily functioning. Conclusions This study showed LATG/JPI to be feasible and safe. With technical modifications, LATG/JPI can become a potentially effective option for improving patients’ quality of life after total gastrectomy.     

全胃切除消化道重建术中空肠储袋的临床研究进展

全胃切除术是常见的胃癌根治术之一。尽管消化道重建的方式繁多,但何种最好尚无定论。经检索近年来有关全胃切除后的消化道重建临床研究报道,主要介绍不同空肠肠袋、Roux-en-Y重建术式的优劣。结果表明,空肠肠袋、Roux—en—Y重建术式并不显著增加手术病死率和并发症发生率,能够改善术后早期食物摄入和体重增加。多数报道认为有利于提高术后生活质量。肠袋重建并未增加手术的风险,而且在早期能改善食物摄入,增加体重,有利于患者术后恢复,一定程度上提高患者生活质量。而患者术后长期效果,由于其影响因素涉及范围广,如地区差异和经济条件等,故要得出一精确结论还有待于进一步的探索。现就非十二指肠径路的主要方式及效果作一简述。     

Jejunal pouch and interposition reconstruction after total gastrectomy for cancer

The authors modified the operative procedures used in pouch and interposition (PI) reconstruction in an attempt to improve the surgical results after total gastrectomy, because a randomized controlled trial had revealed that the clinical assessment of PI was quite poor, even though it is a physiological route. In most of the treated patients, the gastric emptying test revealed delayed emptying, and an X-ray video film showed folding and twisting of the jejunal conduit between the pouch and duodenum, which disturbed the transmission of nutrition. Modified PI (m-PI) was performed by decreasing the length of the jejunal conduit and widening the mesenteric pedicle to preserve the blood and nerve supply. This procedure was retrospectively compared with the previously used PI reconstruction by evaluating the postprandial symptoms, food intake, body weight, serum nutritional parameters, and emptying time of the gastric substitute. The m-PI group (n=6) showed a lower incidence of symptoms, a greater food intake, and a greater weight recovery than the PI group (n=6). The gastric emptying test also revealed an acceptable degree of emptying. We thus conclude that the m-PI reconstruction is more useful for improving the postoperative quality of life than the previously used method of PI reconstruction.     

Improved quality of life with jejunal pouch reconstruction after total gastrectomy

BACKGROUND: There is increasing evidence that the effect of jejunal pouch reconstruction is satisfactory for reservoir function in several randomized control studies. However, these studies were performed in patients with advanced gastric cancer, where significant numbers of the patients died of disease recurrence. In order to exclude the influence of disease recurrence, we performed jejunal pouch reconstruction after total gastrectomy in patients with early gastric cancer in a randomized controlled study and investigated whether or not an improved quality of life (QOL) was observed with jejunal pouch reconstruction. METHODS: Fifty consecutive patients receiving total gastrectomy for early gastric cancer were prospectively divided into the Roux-en-Y reconstruction group without pouch (RY group) or the jejunal pouch reconstruction group (pouch group). Body weight, eating capacity, QOL assessment by gastrointestinal symptom rating scale (GSRS), nutritional parameters, endoscopical examination, 24-hour pH monitoring and Bilitec monitoring were evaluated at 3, 12, and 48 months after surgery. RESULTS: Jejunal pouch reconstruction provided the better QOL than Roux-en-Y reconstruction without pouch both at short-term and long-term periods in a randomized control study. Moreover, as a new finding, pouch reconstruction provided less bile reflux into the esophagus compared with Roux-en-Y reconstruction. CONCLUSIONS: Jejunal pouch reconstruction provided improvement of QOL in patients receiving total gastrectomy.     

Simple versus double jejunal pouch for reconstruction after total gastrectomy

BACKGROUND: Even though many types of reconstruction after total gastrectomy have been proposed to reduce postgastrectomy syndromes, choosing a method that would further improve the quality of life and nutrition of the gastrectomized patient is controversial. Hunt-Lawrence single pouch reconstruction seems to obtain better results compared with the more common Roux-en-Y technique, but both of these reconstructive approaches are associated with some reduction in food intake and some problems in achievement of ideal body weight. METHODS: In this prospective, randomized trial, after total gastrectomy 18 patients had reconstruction according to the Hunt-Lawrence or single pouch technique (SP group), whereas for 23 patients, the technique was modified with construction of a second pouch in the distal portion of the jejunal loop (DP group). Patients in the two groups were compared at 12 months after surgery for problems in gastrointestinal function, quality of life, improvement in body weight and nutritional parameters, serum albumin, hemoglobin level, and serum protein. RESULTS: The DP group demonstrated fewer symptom problems, better weight maintenance, and better laboratory values when compared with patients undergoing standard single jejunal pouch reconstruction. CONCLUSIONS: Reconstruction with use of a double pouch as a gastric substitute leads to better outcome assessments than with a single pouch reconstruction. Our double pouch technique has demonstrated significant improvement in quality of life and nutritional recovery in terms of functional results as well as patient satisfaction.     

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目的评估全胃切除术后,间置空肠代胃术(jejunalpouchreconstruction,JIP)和RouxenY吻合法消化道重建对病人生存质量的影响,以选择最佳的重建方法。方法回顾性分析1990年1月至2002年10月168例病人行全胃切除术后,分别行JIP和RouxenY吻合消化道重建病人术后1年的进食量、体重、血浆营养参数变化、代胃肠管的储存及排空功能、食管下段胆酸及pH值等术后生存质量指标。结果JIP组间置空肠扩张,术后营养状态及生存质量优于RouxenY吻合组,且消化道不良症状及胆汁反流发生率明显低于后者。结论全胃切除后,采用间置空肠消化道重建简单易行,并可明显提高病人术后的生活质量。     

Complication rate after gastrectomy and pouch reconstruction with Longmire interposition

BACKGROUND/AIMS: To determine whether a Longmire-Interposition with or without a pouch used for reconstruction after gastrectomy influences the postoperative complication rate. METHODOLOGY: 49 patients who underwent gastrectomy with Longmire-Interposition with (n = 33) or without (n = 16) an additional pouch and 46 patients with a Roux-en-Y-reconstruction were analysed retrospectively. Complication rate and mortality were studied. RESULTS: There were no significant differences between the reconstruction groups for postoperative complications (Roux-en-Y vs. Longmire-Interposition with and without pouch: 30.4% vs. 28.6% for the morbidity; 4.3% vs. 4.1% for the mortality). CONCLUSION: These findings suggest that a Longmire-Interposition with or without a pouch for reconstruction after total gastrectomy is not connected with a higher morbidity or mortality in comparison to a Roux-en-Y-reconstruction.     

Canine intestinal myoelectric activity after total gastrectomy with jejunal interposition

Changes of intestinal myoelectric activities after total gastrectomy with jejunal interposition were studied in three conscious dogs. Under general anesthesia a total gastrectomy was performed and intestinal continuity was reestablished by a 15 cm jejunal segment interposed between the esophagus and the duodenum. Two electrodes were sown each to the serosal surface of the interposed segment of the jejunum, duodenum, and distal potion of the jejunum, respectively. After recovery from the surgery, the myoelectric activities were recorded for 8 to 12 hours during fasting and after feeding a 200 ml liquid meal. In each segment, total gastrectomy did not alter the initiation of the migrating myoelectric complex (MMC) during fasting. Total gastrectomy also changed neither the postprandial inhibition of the enteric MMC nor the induction of the fed myoelectric pattern after feeding. The way of MMC propagation along the small intestine, however, showed various patterns. Each of three segments generated its own MMCs. Some complexes migrated to the next segment or had an effect on initiating new MMCs of the next segment. Although MMCs occurring in the segment of the interposed jejunum hardly migrated to the adjacent duodenum, some jumped to the distal jejunum. These results suggest that there are no coordinated activities between the interposed jejunum and the duodenum after total gastrectomy with jejunal interposition.     

全胃切除Roux-en-Y加空肠储袋吻合术疗效系统评价

目的 评价全胃切除Roux-en-Y加空肠储袋吻合术的有效性及安全性,为进一步临床研究与循证临床实践提供参考依据。方法 计算机检索有关Roux-en-Y加空肠储袋对比单纯Roux-en-Y的随机对照试验（RCT）资料,检索时间截至2010年10月。由2位研究者逐篇评价纳入研究的质量、交叉核对提取数据,并采用RevMan 5.0软件进行数据处理。结果 共纳入12篇RCT,共577例病人。Meta分析显示：与单纯Roux-en-Y相比,Roux-en-Y加空肠储袋有助于改善术后3个月和6个月的体重,提高术后1和2年的生活质量,降低术后3、6和12~15个月倾倒综合征发生率。另外,两者的手术死亡率、手术并发症发生率及手术时间的差异无统计学意义。结论 Roux-en-Y加空肠储袋与单纯Roux-en-Y吻合术相比在术后近期内存在优势,而远期疗效仍须进一步研究证实。     

Chronic outcome of proximal gastrectomy with jejunal pouch interposition in dogs

BACKGROUND: To prevent or minimize postgastrectomy complications, proximal gastrectomy with an interposed jejunal pouch has been advocated as an organ-preserving surgical strategy to improve quality of life for the patients. However, the utility of this surgical method has only been evaluated clinically and no reports have been published concerning animal studies. Therefore, we carried out an experiment in beagle dogs to investigate the utility of proximal gastrectomy with an interposed jejunal pouch. METHODS: Female beagle dogs weighting 8.0-10.0 kg were divided into two groups that underwent proximal gastrectomy with jejunal pouch interposition (JP group) and esophagogastrostomy (EG group). The time course of the electrophysiological changes on electromyograms were compared between the JP and EG groups. RESULTS: Electrophysiologically, a significant difference was noted between the two groups on the number of action potentials per unit time, the mean amplitude, and the length of the resting period in the preprandial state. All parameters tended to be normalized sooner after surgery in the JP group. CONCLUSIONS: The clinical superiority of jejunal pouch interposition was suggested experimentally to the same extent on electromyograms.     

全胃切除术后保留幽门环间置空肠消化道重建与食管空肠Roux-en-Y吻合的应用价值

目的评价全胃切除术后保留幽门环间置空肠消化道重建与食管空肠Roux-en-Y吻合两种消化道重建方式的临床应用价值。方法总结30年来全胃切除术后采用保留幽门环间置空肠消化道重建术与食管空肠Roux-en-Y吻合术治疗54例胃底贲门癌和胃体癌(Ⅰ期)患者的临床资料。结果间置空肠消化道重建术27例,无手术死亡;其中1例术后5d出现间置空肠排空障碍,经治疗3周恢复正常;27例均治愈出院;术后6个月～1年,全组均进食量增加,每餐可达200～300g,每日3～5餐;检查见间置空肠代偿性扩张,最大直径达6cm。食管空肠Roux-en-Y吻合术27例,无手术死亡;25例治愈出院;2例吻合口瘘,经治疗3周后瘘口愈合;术后6个月仍有3例发生倾倒综合征,5例出现轻度胆汁反流性食管炎。结论保留幽门环间置空肠消化道重建术是简单可行而有效的方法。食管空肠Roux-en-Y吻合术更为简单,适用于年老、重症或姑息性全胃切除的患者,但部分患者可出现倾倒综合征和反流性食管炎是其缺点。     

Jejunal pouch interposition after pylorus-preserving gastrectomy.

BACKGROUND: To improve the quality of life of patients undergoing gastrectomy, a nerve-conserving jejunal pouch was interposed after pylorus-preserving gastrectomy (PPG) with vagal nerve preservation. We report the details of the operative technique and the outcome. METHODS: PPG with lymph node dissection was performed, preserving the hepatic, pyloric, and celiac branches of vagal nerve. The jejunum was cut approximately 20 cm distal to the ligament of Treitz. Marginal vessels were not divided in order to preserve the nerves in the jejunum that were used to construct the pouch. A linear stapler was used to perform a side-to-side jejunojejunostomy. A 12-cm-long pouch was formed by firing the stapler twice. The pouch was interposed between the residual parts of the stomach. Postoperatively, the patients were interviewed periodically. A dual-phase, dual-isotope radionucleid pouch-emptying study was performed 6 months after surgery. RESULTS: A total of 13 patients underwent the operation. No complication developed. During the first 6 months after surgery, the body weight of the patients was maintained at 91% of the preoperative level. The radioisotope retention rate for the combined pouch and residual stomach was 46% for liquid food and 76% for solid food 120 min after ingestion. The pattern of its emptying was similar to that in healthy individuals. CONCLUSIONS: The pouch-emptying test demonstrated a satisfactory retention capacity and acceptable emptying for the gastric substitute. A reasonably good quality of life has been obtained for patients undergoing PPG with interposition of a nerve-preserving jejunal pouch.     

Postoperative functional evaluation of jejunal interposition with or without a pouch after a total gastrectomy for gastric cancer

BACKGROUND: The objective of this study was to compare the motility of a gastric substitute after jejunal interposition without a pouch and jejunal interposition with a pouch and to evaluate the relationship of both methods with nutritional outcome. METHODS: Twelve patients with gastric cancer treated by total gastrectomy and reconstruction with jejunal interposition without a pouch (J-I) and 14 patients treated by total gastrectomy and reconstruction with jejunal interposition with a pouch (J-P) were investigated in regard to the motor activity of the interposed jejunum and changes in body weight and dietary intake. RESULTS: Phase III of the interposed jejunum without a pouch was observed over a 3-month follow-up, but phase III of the interposed jejunum with a pouch was not observed in any patient within 3 months of surgery. In the fed state, the motor activity of the interposed jejunum without a pouch increased significantly in patients within 12 months of follow-up, but in the interposed jejunum with a pouch, it did not. The amount of food consumed by the J-I group was significantly greater than that consumed by the J-P group. CONCLUSIONS: This study demonstrates that the interposed jejunum with a pouch shows marked disturbances from the motor pattern of a normal jejunum during the fasting and fed states. These motor abnormalities may be responsible for insufficient food intake of the J-P group.     

全胃切除改良功能空肠间置法胃肠道重建

全胃切除术后并发的反流性食管炎、倾倒综合征、食欲减退、摄食不足、消化不良、体重下降及贫血等无胃综合征,严重影响患者生活质量,故应寻找一种合理的消化道重建方式。郝希山等[1]创用功能性空肠间置代胃术(functional je-junal interposition,FJI,1999年),我们认为更符合生理,并在此基础上进一步加以改良,报告如下。1资料与方法1.1一般资料2004年7月至2005年1月,术前通过胃镜病理确诊,全胃切除术后有完整病历资料的10例。男7例,女3例,年龄45~68岁。均为胃上、中部癌,贲门癌3例,胃体小弯侧5例,大弯侧1例,累及整个小弯1例。BorrmannⅢ型9…     

The uncut Roux-en-Y with jejunal pouch: a new reconstruction technique for total gastrectomy

BACKGROUND: Roux Stasis Syndrome is a well-known complication after Roux-en-Y reconstruction. It has been hypothesized that reconstruction with an uncut Roux limb and jejunal pouch after total gastrectomy would preserve unidirectional intestinal myoelectrical activity, improve postoperative weight gain and nutritional parameters, and diminish Roux Stasis Syndrome in canines. METHODS: A total gastrectomy was performed, and 2 methods were used for reconstruction: Roux-en-Y esophagojejunostomy (RY) was performed on 5 canines (control), and the uncut Roux-en-Y with a jejunal pouch (URYJP) was performed on 5 other canines (experimental). The canines were monitored for 10 weeks postoperatively. Serial weight and nutritional parameters were measured. Emptying profiles and motility studies were performed in the fasting and postprandial states. RESULTS: Ten weeks after operation, the URYJP group had significantly improved nutritional parameters, including weight, total protein, albumin, hemoglobin, serum total iron binding capacity, and serum IgA, IgG, and IgM. The emptying times for both groups were similar, with an increase of disordered propagation of the jejunal pacesetter potential in the RY group. The aboral propagation occurred more frequently in the URYJP group during fasting and after feeding (98% +/- 1% vs 39% +/- 16%; P = .02, and 99% +/- 1% vs 43% +/- 18%; P = .03). The sites of luminal occlusions were intact in the URYJP group at 10 weeks. CONCLUSIONS: The combination of jejunal pouch and uncut Roux limb improved overall nutritional parameters when compared with the traditional Roux-en-Y, while preserving aboral propagation of jejunal pacesetter potentials.     

Dai-kenchu-to, a Chinese herbal medicine, improves stasis of patients with total gastrectomy and jejunal pouch interposition

BACKGROUND: Intestinal motility after gastric surgery frequently is disturbed and results in postoperative intestinal symptoms and poor quality of life (QOL). The purpose of this study was to examine the effects of Dai-kenchu-to on intestinal motility and postoperative QOL of patients. METHODS: Seventeen patients who underwent total gastrectomy with jejunal pouch interposition for gastric cancer in the Department of Surgery of Osaka University Medical Hospital were enrolled. The patients were assigned randomly to the cross-over study with or without 15 g/d of Dai-kenchu-to. Questionnaires and emptying tests using (111)In-labeled liquid and (99m)Tc-labeled solid test meal were performed at the end of each treatment period. A manometric study was performed in 6 patients to measure contractile activity with or without Dai-kenchu-to. RESULTS: Stasis-related symptoms were reduced significantly by Dai-kenchu-to (P = .032). In the emptying test, Dai-kenchu-to accelerated emptying of both liquid (P < .01) and solid (P = .015) meals from the pouch. The pouch showed bursts of contractions, which were increased significantly by oral intake of Dai-kenchu-to (P = .028). CONCLUSIONS: Dai-kenchu-to increased intestinal motility and decreased postoperative symptoms of patients with total gastrectomy with jejunal pouch interposition.